Initial Warfarin Review

The following recommendations should be followed for ALL patients started on warfarin:

Review the contraindications to therapy and the clinical conditions that may increase risks associated with warfarin therapy. Also make sure there is a valid indication for starting warfarin.

A thorough review of the following should be completed: diet, current drug therapy (interacting medications), OTC use (herbal products, NSAID use etc).

Initial doses of warfarin may range from 2.5 to 10 mg depending on the
presence of risk factors for bleeding. Loading doses (e.g. doses >10mg) are
NOT recommended (refer to the 9th ACCP- Chest guidelines).

Patients who are at an increased risk of bleeding such as the elderly (> 65 – 70 yo) or patients with CHF/ liver disease / debilitated / recent major surgery / or patients receiving medications known to potentiate the action of warfarin are usually started at the low end of this range e.g. 2.5 - 3 mg.

The following monitoring guidelines should be followed:

A baseline INR should be obtained IN ALL CASES.

Determine the INR daily after the administration of the initial dose until INR results stabilize in the therapeutic range.

After stabilization, maintain dosing within the therapeutic range by performing periodic INRs. The frequency of performing INR should be based on the clinical situation but generally acceptable intervals for INR determinations are 1 to 4 weeks.

Perform additional INR tests when other warfarin products are interchanged with COUMADIN, as well as whenever other medications are initiated, discontinued, or taken irregularly.

Contraindications / Clinical Conditions (REVIEW)

CONTRAINDICATIONS

Pregnancy
COUMADIN is contraindicated in women who are pregnant except in pregnant women with mechanical heart valves, who are at high risk of thromboembolism. COUMADIN can cause fetal harm when administered to a pregnant woman. COUMADIN exposure during pregnancy causes a recognized pattern of major congenital malformations (warfarin embryopathy and fetotoxicity), fatal fetal hemorrhage, and an increased risk of spontaneous abortion and fetal mortality. If COUMADIN is used during pregnancy or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to a fetus

Hemorrhagic tendencies or blood dyscrasias

Recent or contemplated surgery of the central nervous system or eye, or traumatic surgery resulting in large open surfaces

Deficiency in protein C-mediated anticoagulant response: COUMADIN reduces the synthesis of the naturally occurring anticoagulants, protein C and protein S. Hereditary or acquired deficiencies of protein C or its cofactor, protein S, have been associated with tissue necrosis following warfarin administration. Concomitant anticoagulation therapy with heparin for 5 to 7 days during initiation of therapy with COUMADIN may minimize the incidence of tissue necrosis in these patients.

Eye surgery: In cataract surgery, COUMADIN use was associated with a significant increase in minor complications of sharp needle and local anesthesia block but not associated with potentially sight-threatening operative hemorrhagic complications. As COUMADIN cessation or reduction may lead to serious thromboembolic complications, the decision to discontinue COUMADIN before a relatively less invasive and complex eye surgery, such as lens surgery, should be based upon the risks of anticoagulant therapy weighed against the benefits.

Polycythemia vera

Vasculitis

Diabetes mellitus

Geriatric Use: Patients 60 years or older appear to exhibit greater than expected INR response to the anticoagulant effects of warfarin. COUMADIN is contraindicated in any unsupervised patient with senility. Observe caution with administration of COUMADIN to elderly patients in any situation or with any physical condition where added risk of hemorrhage is present. Consider lower initiation and maintenance doses of COUMADIN in elderly patients.

[]
Labile INRs (refers to unstable/high INRs or poor time in therapeutic range(eg<60%)

[]
Drug Therapy (concomitant therapy such as antiplatelet agents, or NSAID's that may increase risk)

Reduced platelet count or function [
] and/ or Anemia [ ]

[]
Excessive fall risk?

[]
Genetic factors (CYP2C9 variant)

B]Gender:

C] Select NOMOGRAM:

Note: If a custom
nomogram is selected please select the
starting dose:
mg
(Starting dose should be based on patient age; presence of interacting
medications;
and bleeding risk of patient.)

Baseline INR and CBC should be obtained prior to initiation of warfarin therapy.

Overview: [all
nomograms are based on INR values obtained daily in order to
predict/determine the maintenance dose requirements.] Once a
patient stabilized (two therapeutic levels 24 hours apart), follow-up
monitoring should occur approximately weekly for the first month (initiation
phase).

Standard: Initiation
regimen for most patients unless factors are present that may significantly
increase or decrease the response to warfarin. Using higher doses e.g.
7.5 to 10mg for an average patient with no known risk factors for bleeding
is more likely to result in overanticoagulation.

High-risk: Patients
who are at an increased risk of bleeding such as the elderly (> 70-75) or
patients with CHF/ liver disease / debilitated / recent major surgery /
impaired
nutritional intake/ or patients receiving medications known to potentiate
the action of warfarin (e.g. amiodarone or similar medications). Increased
baseline INR.

Low-risk: Young
patients with a LOW risk of bleeding, especially if very large; receiving
medications known to decrease the response to warfarin; concurrent
medical condition(s) such as clinical hypothyroidism that may reduce
response to warfarin. In selected patients (e.g., very large
individuals or those on medications known to antagonize warfarin), a Day 1
warfarin dose of 7.5 mg may be appropriate.

The authors
make no claims of the accuracy of the information contained
herein; and these suggested doses and/or guidelines are not a
substitute for clinical judgment. Neither GlobalRPh Inc. nor any other party involved in the
preparation of this document shall be liable for any special,
consequential, or exemplary damages resulting in whole or part from any
user's use of or reliance upon this material. PLEASE
READ THE DISCLAIMER CAREFULLY BEFORE
ACCESSING OR USING THIS SITE. BY ACCESSING OR USING THIS SITE, YOU AGREE
TO BE BOUND BY THE TERMS AND CONDITIONS SET FORTH IN THE DISCLAIMER.

You must confirm that you have
READ and
AGREE with the terms and conditions listed above
before continuing:

Crowther et al. (Comments:
Initial development of a warfarin initiation nomogram for
thrombosis treatment. Provided guidance for dosage
adjustments from day#2 through day #6 starting with an
initial dose of 5mg on day #1 of therapy).

Haines et al. (Comments:
Listed two nomograms with common dosage reduction patterns
found in other nomograms. Because the listed
dosage modifications are listed as percentages, this type of
dosing scheme can be easily manipulated by a computer program
to accept any starting dose and then dynamically create a new
nomogram based on the initial starting dose. Further
enhancements can be added such as sophisticated rounding
methods that generate common warfarin dosages as well as
additional guidance based on a few simple web-form inputs. )

Kovacs et al. (Comments: Modified the 5mg nomogram developed by Crowther et al (1997): The new nomogram started
with two initial 5mg doses followed by potential dosage modification
on day #3 instead of day #2. Also developed a10mg warfarin
initiation nomogram with mandatory monitoring and potential
modification on Day #3 and Day #5 of therapy. )

Disclaimer

All calculations must be confirmed before use. The authors make no claims of the accuracy of the information contained herein; and these suggested doses are not a substitute for clinical
judgement. Neither GlobalRPh Inc. nor any other party involved in the
preparation of this program shall be liable for any special, consequential, or exemplary damages resulting in whole or part from any user's use of or reliance upon this material.PLEASE READ THE DISCLAIMER
CAREFULLY
BEFORE ACCESSING OR USING THIS SITE. BY ACCESSING OR USING THIS SITE, YOU
AGREE TO BE BOUND BY THE TERMS AND CONDITIONS SET FORTH IN THE DISCLAIMER. Read
the disclaimer